Date Today: *

Evaluated by: *

Surrendering Person Information:

First Name *

Last Name *

Phone *

Email *

Street Address *

City

State

Postal code

Keeping Until Adopted? *

Yes

No

OWNER: How long?

STRAY: How long held?

STRAY: Location Found:

Surrendered Animal Information:

Animal Name *

Age/DOB: *

Gender: *

Male

Female

Breed: *

Color: *

Weight *

Animal Spay/Neuter Status *

Yes, spayed or neutered.

No, not spayed or neutered.

Pending Appointment.

Animal Personality:

Does the dog have experience with children? *

No experience with

Tolerates them

Enjoys them

Loves them

Only with older children

Dog's Experience with Strangers: *

None

Friendly

Reactive-Barking

Reactive-Growling

Hiding/Fearful

Does the dog have experience with cats? *

None

Yes, outside cats

Yes, inside cats

Dog's personality with cats:

Chases

Ignores

Befriends

Injures

Does the dog have experience with other dogs? *

None

Reactive-Barking

Reactive-Growling

Reactive-Lunging

Shares Food

Guards Food

Guards Toys

Is the dog crate trained? *

Yes

No

Is the dog leash trained? *

Yes

No

Is the dog housetrained?

Yes

No

Partially

Is the dog pee pad trained? *

Yes

No

Doesn't Apply

Previous Bite History? *

Yes, humans

Yes, cats

Yes, other dogs

No to all

3 DOG PERSONALITY PROS: *

3 DOG PERSONALITY CONS: *

Once an animal is up for adoption through MARC, adoptor must be screened by MARC. The Animal can not be given away or kept without MARCs permission. A reimbursement of $175 is required for vetcare and resource expenses.

Surrender Person Signature *

Clear

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